Why you should not decide when to get on or off the diabetes medicines

Across the table from me was a draught, hassled overweight young woman. She had just been diagnosed with a urine infection. “I have high blood sugar but I can’t understand the reason. I exercise, eat healthy, yet my sugar values don’t seem to respond. I am certain there is something grievously wrong with me and no one is able to tell me what it is!”
After calming her down, I proceeded to elicit her hory. Two years ago, during a routine check-up, the 35-year-old Manisha (name changed) was detected to have high blood glucose (>300 mg/dl) and was advised medication. She, however, was determined to take charge of her condition and manage without medication. She stopped monitoring her sugar.
On being diagnosed with urine infection, she was asked to check her sugar, and the readings were >200 mg/dl, with a three-month Hba1c average of nine per cent (as against <6.5 for someone without diabetes). Despite being in this situation, Manisha was clear about one thing. She did not want medication, which she thought would be addictive and damage her organs! Besides, she didn’t trust allopathy and allopathic doctors. After some patient hearing and gentle persuasion, I managed to convince her to start medication. Her sugar levels are now controlled and she is feeling fine.

Manisha is not alone. There are many like her we see in our daily practice. Why would highly educated, well-read people refuse medication? This phenomenon is not limited to Indians. Studies have shown that about 40 per cent of people with diabetes do not take medication as directed.
Why do people refuse or give up medication?There are several reasons:
(a) Fear of addiction: Many like Manisha feel that medicines are addictive and once on them, they can’t get off them. However, in the initial stages of Type 2 diabetes, those who ensure strict lifestyle measures and lose weight can sometimes go off medication. For those who continue to require medication, it is because the diabetes is permanent, not because starting the drug has made them addicts!
(b) Fear of side effects: Another concern that Manisha had and is shared many is the fear of side effects and damage to vital organs like kidney and liver. This is particularly true if someone in the family has faced adverse effects. While it is true that all medication can have some side effects, they are rare, and your doctor will periodically monitor you. Minor side effects like gastritis or urinary issues can easily be managed your doctor. Hidden, serious adverse effects on the liver and kidney are virtually unknown with diabetes medication. It is uncontrolled diabetes that damages our eyes, heart, liver and kidney, not the medicines.

(c) Lack of symptoms: Since chronic disorders like diabetes and hypertension do not produce any symptoms except in extreme situations or when complications have set in, the patient feels no different whether or not they take the medication, leading many to abandon them.
(d) Lack of awareness/poor communication: A very important component of diabetes care is explaining the benefits of the medication and any possible side effects. “Why am I taking this medication” is an oft repeated question. If patients know a medication may cause low sugar, they will be more careful with meals and glucose monitoring. Likewise, if they know a medication may cause nausea, they can take it with food. Sometimes regimens are complex with multiple medications, different timings, requiring detailed explanation. Often doctors don’t have time so an educator/nutrition takes up this role.
(e) Discontinuing medication once test results are normal: It’s critical for patients to understand that the results are normal because of the medication, and the disease has not resolved. Medicines have to be continued unless the doctor advises otherwise.
(f) Sense of failure: One category of patients who are fit and lead healthy lifestyles feel that they will be able to manage their condition and takig medication is admitting to defeat. Very often, lifestyle measures alone may suffice in the early stages, but since the disease is progressive, medication is required at some stage for almost all people with diabetes.
(g) Mrust: There are some out there who feel the whole medical world is a scam and it’s all a conspiracy hatched big pharma with the active connivance of doctors. While there are some bad eggs in every profession, the vast majority of doctors prescribe medicines only for the benefit of their patients. In case you have any doubts, find a doctor- usually word of mouth- whom you can trust. Once you have chosen a doctor, please follow their advice rather than suspect every action.Fear of needles can be a reason for some to avoid insulin and some other drugs. Modern technology has made insulin injections much easier and comfortable. Ask your doctor’s team for a demo. Insulin is an amazing tool for treating diabetes and to deny yourself its benefit because of irrational fear will be disservice to yourself.
(h) Cost: This is the most important reason for people discontinuing medication. The greater availability of lower priced generic medication in India will hopefully alleviate this problem to a large extent.
Diabetes is a progressive disorder, and, though diet and exercise are the first line of treatment, medication is necessary for most patients at some point in the course of their disease. Medications help us fight the disease and improve outcomes. Yet more than half the patients fail to achieve good glucose control. Besides, newer medications don’t just control blood glucose, they also reduce the risk of kidney, heart and liver complications. Let us resolve to fight the malady, not the medication.
(Dr Mithal is a Padma Bhushan and and Dr B C Roy awardee)